Urinary continence scores (data not shown) and the mean age at toilet training were similar between the patients and controls (Table 5). Occasional (<1/week) daytime or nighttime wetting occurred in 3 patients.
In this controlled survey we examined functional long-term outcome in boys treated for perineal fistula with anoplasty. We examined all consecutive boys with perineal fistula between 1992 and 2001, and included only boys with perineal fistula to ascertain homogeneity of the study group. Moreover, caregivers of the patients and the controls were interview by an independent nurse specialist who had not been involved with surgical management of the patients. Comparison to a sex- and age-matched control group showed that as many as one third of boys with perineal fistula have impaired anorectal function, which was mainly attributed to constipation and soiling.
Perineal fistula may be viewed as the least severe form of anorectal malformation. Accordingly, functional outcome associated with perineal fistula should represent the best possible outcome after surgical correction of an anorectal malformation. In this light the results of the present study are not fully satisfactory, but they are in line with the findings of a previous controlled follow-up study including several types of low anorectal malformations in both sexes (3,4). The overall degree of functional impairment found in the present study may be classified as mild in terms of mean or median numeric scores, although individualized assessment gives a somewhat different picture. For example, 5 patients (23%) required laxatives for constipation, 12 patients (55%) had occasional soiling, and 5 patients (23%) had occasional fecal accidents. However, statistically significant differences in relation to the control group were observed only for constipation and soiling, underlining the importance of an adequate control group.
Constipation is a common finding after surgical repair of low anorectal malformations, occurring in approximately 50% of patients (4,5,7). The reason for constipation remains unclear, and it seems to occur similarly regardless of surgical technique used (4,5,7). Our finding of a 42% constipation rate is in accordance with the findings of previous reports (4,7). Occurrence of constipation following anoplasty requiring limited surgical dissection suggests that constipation is mainly caused by the anomaly itself rather than by the operation.
Previous studies have reported soiling frequencies between 9% and 12% in patients with low anorectal malformations (4,6,7). In the present study the frequency of soiling among boys with perineal fistula was clearly higher (55%). We defined soiling as fecal staining of underwear. In all cases soiling occurred less than once per week and did not require treatment in any case. Soiling was also relatively common among the controls (24%). Nevertheless, the difference is statistically and clinically significant. In our study the caregivers were interviewed by an independent nurse specialist instead of surgeons or nurses directly involved with patient care. We believe that more reliable and honest information is received when interviews are accomplished by an independent third party.
In cases of perineal fistula, the anus, although anteriorly displaced, is surrounded by the sphincter muscles. One may accept the anterior displacement of the anus and perform a simple anoplasty as in the present series, or perform more invasive posterior sagittal anorectoplasty in which the rectum is mobilized and brought into the middle of the sphincter complex, followed by reconstruction of the anal sphincters (8). It may be argued that the latter surgical approach is associated with better functional outcome. We have recently completed a comparison of functional outcomes between these 2 surgical techniques. Preliminary results suggest that functional outcome is similar after both procedures (9). In addition, the rates of constipation, soiling, and totally continent patients are comparable in case series of perineal fistula managed with posterior sagittal anorectoplasty and in follow-up studies after anoplasty (4,7).
In conclusion, overall long-term bowel function is impaired in one third of boys with perineal fistula treated with anoplasty. The main reasons for impaired anorectal function are constipation and soiling, which affect as many as half the patients. In most patients the nature of constipation and soiling is modest enough not to produce social problems or restrict social activities. Patients with operatively treated low anorectal malformations require continuing follow-up and care beyond childhood.
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Keywords:© 2007 Lippincott Williams & Wilkins, Inc.
Anoplasty; Boys; Functional outcome; Perineal fistula